Tag: clinical management

Posted in Cardiovascular system, Chronic disease management, Diagnosis, Heart Failure, Uncategorized

Heart Failure – the need to knows

Posted on by Emma

Heart failure is a condition we are increasingly seeing as the population ages. According to figures there are approximately 900,000 people in the UK with a diagnosis of heart failure. It is likely many more remain undiagnosed.

Why is it important to a GP? Because it is often our doors that patients arrive at with symptoms of undiagnosed heart failure, or for management of their already diagnosed heart failure. So we need to remember to consider it as a diagnosis, know what other points in their medical history are relevant, how to investigate and how to manage heart failure.

An important learning point – from prior experience – keep heart failure as a differential diagnosis in all patients presenting with symptoms of breathlessness, regardless of age or lack of other risk factors. It is not difficult to include it in your investigations so keep it on the list until you’ve excluded it via tests.

Firstly, we need to think of the way people might present with heart failure. I am not going to cover an exhaustive list of all of the symptoms because you should know this by now. But people often come to see their GP with symptoms of breathlessness ( to differing degrees), fatigue, or very commonly – ankle swelling. All of these symptoms have multiple potential diagnoses, and it is through further questioning and consideration that you are going to consider whether heart failure is on your list of differentials. If it is then your first step is going to be the trusty BNP or NTproBNP blood test.

BNP/ NTproBNP

These peptides are sensitive enough to use as a diagnostic tool for detecting heart failure. But they are not quite as specific. Carrying out a blood test to check the levels of either of these peptides is going to help you both diagnose or exclude heart failure.

But what other factors or conditions can affect the BNP result?

Falsely lower Falsely higher
Obesity Tachycardia
Diuretics LVH
ACE Inhibitors Hypoxaemia
ARBs eGFR < 60
Beta- blockers COPD
Diabetes
> 70 years
Cirrhosis

Note the above features – this is going to influence the other elements of your assessment. In order to help you interpret the result you need further information. You need their medical history, medication list and some examination findings.

Notably you might need to weigh your patient to look for their BMI. You need to know what their pulse is and the regularity of it. In addition, an ECG isn’t going to go amiss. From that you can look for SVTs, LV strain and signs suggestive of ischaemia.

In addition to the BNP you want to get some additional blood results:

  • Renal function
  • Liver function
  • Thyroid function
  • Lipids
  • HbA1c

*An off-track learning point – I am pretty tough on trainees at times when it comes to requesting bloods and tests. Why? Because they are expensive and you need to interpret them! When I undertook my emergency medicine rotation I worked in a hospital where the pathology lab was off site. During the induction they told us that we shouldn’t be ordering bloods unless we were planning to admit the patient, because the chances were that the results would not be available before the 4 hour see and treat time was up. Unless you’ve experienced this you will not appreciate how liberating it is to go back to using a history and examination to diagnose a patient. General practice has very much the same ethos. It can be really tempting when requesting a blood test to tick a load of other boxes ‘whilst we are at it’. Don’t. Have a rationale for each test you undertake – what are you looking for and why is it relevant. I’m not going to spell it out for you for the above tests but have a think why they might be relevant!

Interpreting the result

We now have a patient with some symptoms suggestive of heart failure and a positive BNP. What do we do now?

Well we need to look for the cause, unless it is glaringly obvious. The chances are we need an ECHO to help us with this. But how urgently do we need an ECHO? We are going to split our patients into three different categories (as suggested by NICE guidance), and this is going to help us treat our patient within an appropriate time frame:

  1. A very raised BNP (> 400pg/ml) or NTpro BNP (>2000pg/ml) – levels like this carry a poor prognosis so refer urgently to the heart failure clinic for further assessment.
  2. A past medical history of a myocardial infarction (MI) – refer for an ECHO and specialist assessment within two weeks.
  3. Other patients – need an ECHO within 6 weeks of the abnormal BNP result.

The result of the ECHO is going to split our treat versus refer patients even further. Who will we refer?

  • Patients with a preserved ejection fraction
  • Valve disease – I think there is some scope to be rational with this group of patients. Read the ECHO report and refer sensibly. A very mild aortic stenosis in an 80 something year old may not necessarily require immediate referral.

So the other patients, i.e. those with left ventricular systolic dysfunction, are the ones we are going to get on and treat.

Mangement principles

  • Effective communication regarding the diagnosis
  • Lifestyle measures
  • Drug treatment
  • Consider the psychological impact of the disease

Communication – You need to explain the diagnosis clearly and carefully. Heart failure is probably a scary diagnosis to a patient. They are being told their heart is failing. We need a heart to live, and theirs is failing! You need to turn this into a less scary situation with a very good explanation and reassurance that there are ways of helping them. Think about how you might explain this diagnosis, and perhaps try your explanation out in a role play setting.

Lifestyle measures – There are a number of changes patients can make that could help to improve their symptoms and outcomes. Increasing exercise as best they can, stopping smoking, reducing alcohol intake and receiving their annual influenza vaccine.

Drug treatments – Keep this simple in your mind.

  • First line:
    • ACE Inhibitors & Beta-blockers – titrate your ACE inhibitors every two weeks (keeping an eye on the renal function) and start with a low dose and gradually increase (perhaps alongside the ACE inhibitor). Make sure you keep an eye on the heart rate when titrating the beta-blocker. If your patient has a home BP monitor then it is worth suggesting the patient check their blood pressure and pulse if they are feeling dizzy or unwell. An ARB is a suitable alternative if the ACE inhibitor is not tolerated.
  • Second line:
    • At this stage you might wish to consider seeking specialist advice but the following medications can be used in the management of heart failure:
      • Aldosterone antagonist (Spironolactone) – for moderate to severe heart failure, or oedema in congestive heart failure.
      • ARB (Candesartan and Valsartan) – mild to moderate heart failure.
      • Hydralazine + Isosorbide dinitrate – moderate – severe heart failure.
      • Digoxin – will improve the symptoms but will not improve mortality. Use in worsening or severe heart failure where patients are already taking maximal treatment with the above mentioned medications.
  • Diuretics:
    • Use for the relief of congestive symptoms and fluid overload.
    • They can be titrated up and down as required.
    • If a patient is requiring greater than 80mg Furosemide daily then you should refer them onwards.
    • Whilst using diuretics you should monitor every six months via a blood test and medication review.

As with all chronic diseases it is important to consider the psychological impact upon the patient. You should address this at their reviews, and manage as required. Locally in Peterborough the psychological wellbeing service has capacity to provide support to individuals who are suffering from chronic disease such as COPD and heart failure. This part of the management shouldn’t be under-estimated. You can spend your days treating disease and illness, but you can’t lose sight of your patient as a whole.

I hope this has been a helpful summary of how to work up a patient for heart failure, and the basic management approach.

Posted in Consultation skills, CSA, Diagnosis, MRCGP

CSA – What’s clinical management all about?

Posted on by Emma

I went to the autumn seminar at the end of September, and I saw a session on clinical management in the CSA. So I circled it and made sure to attend. Having sat the CSA myself I really couldn’t say with certainty exactly what they were looking for. I have also found this with trainees I have helped prepare since. I think the data gathering section is obvious (because you need to take a thorough yet relevant history), and interpersonal skills are also pretty straightforward. But with the clinical management it’s hard to be sure whether we are supposed to have a clear diagnosis, whether we need to show the examiner we know everything there is to know about a topic, give 10 options to the patient, or completely cure them in one consultation!

In addition, the commonest CSA feedback statements are related to clinical management, and this is where trainees are most likely to lose marks.

This session was, by far, the most useful I have attended to date. So I thought I would share some of my learning from it. It was led by Dr Roger Tisi, who is the Associate Postgraduate Dean for Health Education East of England. All credit is to him for making things clearer, and being a great presenter! In addition, this information is from his session so I must also credit him for the knowledge I pass on.

The first point that was made clear is that we should consider that we aren’t just getting 3 marks for the clinical management section. We should assume that half the marks for each station are related to clinical management since interpersonal skills run throughout, and are linked in with a good management plan.

The commonest pitfalls in the CSA are what we all know they are – running out of time, missing the point and managing a condition but not managing the patient who has the condition.

A lot of people in this session noted they would see a clear drop in energy levels as a trainee reaches the second half of the consultation. So you need to think about how you might keep that energy up, and provide a great management plan. Some suggestions included repositioning yourself and straightening your posture, taking a deep breath, etc. The clinical management section begins at the time that you put a possible diagnosis on the table. One possible way to ease in to the clinical management section is to repeat their ideas, concerns and expectations back to them. You might want to think about how you phrase this, but if you can achieve this then you know that you’ve got to the bottom of this consultations, and are on the right tracks. In addition, it means you are more likely to manage the patient and the psychosocial context rather than just the condition in general.

What I took away that is very important is that the CSA doesn’t require you to have a diagnosis in every case. You may be creating a differential diagnosis, or dealing with a dilemma, or providing something else such as advice or support. Remember this – how many times per session do you sit and listen to a history and make a definitive diagnosis at the first appointment? I know that I often come up with some differentials, and have to undertake some further investigations to create a diagnosis and an appropriate management plan. So if it’s ok in real life, it’s ok in the CSA!

You need to provide your explanations in such a way that both the patient and the examiner can understand. You may wish to refer back to any concerns the patient has raised here. Something I like to do, and that we discussed in this session, is thinking out loud (We’ll call it the Em Sheerham technique). Sometimes you have a lot of thought running through your head ‘it could be this or it could be that’, ‘to decided I think I need to do this or that’, ‘normally we’d do this but this patient is that’. If you sit in silence having those thoughts it looks awkward, and also no-one knows why you then come up with the plan you have made. In addition, if you’ve thought it all through in your head then there’s a good chance that when you verbalise it you do it in such a way that you don’t give the full information. Instead, say it out loud – confidently. If you do this then both the examiner and patient see where you’re coming from and understand your rationale. They are more likely to get on board if you make it clear what your thinking is.

Just to reiterate – you must put it into the context of the patient you have sat in front of you. E.g. the lady that’s had a funny turn (possible seizure) who drives for a living, the contraceptive advice for the 15 year old who’s boyfriend is 19. It might be when doing this that you realise you’ve missed a crucial piece of information. If you have then signpost that you hadn’t asked a question that may be of relevance and then ask it. The examiner might realise for the first time that you’ve missed something here so be careful!

Options, options, options! Guess what – sometimes it’s ok to give few or non-options. On the basis that you keep it patient centred, and explain your rationale. E.g. the patient who is worried he may have cancer, and you’re worried he has cancer. The only real option is 2WW referral – so that’s what you’re going to offer – just explain why! You need to inform the patient to allow them to be involved in the decision process, whether there are lots of options or none. Again, this is whether thinking aloud helps, and remembering that the consultation is a dialogue or a conversation – not a presentation!

But whatever you do – do something! A really good point that Dr Tisi made was that the examiner might ask himself at the end of the consultation ‘Is this patient better off for having seen this doctor today?’ They want to be able to say yes, and if you do nothing at all then the answer will be no. So make a plan that the patient is happy with and go with it. Do not run out of time before you’ve done this.

Make sure the patient knows what the plan is, agrees with it, knows how it is to be executed, and there is follow up to ensure patient safety. Be clear on it. E.g. if you say you’ll get in touch with them then tell them how e.g. telephone, writing to them or face to face.

Last crucial point – DO NOT AVOID THE ELEPHANT IN THE ROOM! It is in the CSA for a reason. However painful you might think it will be to address the 14 year old with the 20 year old boyfriend, the drug addict, the patient with back pain who probably has bone metastases, etc. You must address this, otherwise chances are you will fail!

Few little pointers:

  • Video consultations – watch some of your own and check whether you are a serial word user. This can be annoying to an observer so just be careful! I remember I used to say ‘I think’ a lot, and my supervisor pointed out that I sound unconfident, even when I knew I was doing the right thing.
  • Stock phrases such as ‘what were you hoping I could do for you today?’ need to be used carefully, and in the appropriate context. Otherwise they just sound wrong, patronising, ridiculous. If a phrase is completely out of your comfort zone then don’t bother with it.
  • Patient preference doesn’t always take preference. It’s Ok if you don’t give the drug addict more fentanyl patches.
  • Consultations don’t necessarily have to end on a positive note – e.g. as with the above scenario. But this shouldn’t be due to an inappropriate management plan or lack of consultation skills!

You just need to practice all of this, and with time it will just flow. Remember if you need to practice explaining diagnoses or treatments then the best person you can find is a non medical friend or relative. You can easily work on a jargon free explanation with said individual!